Top 10 tips to improve
postoperativ care
 

Top 10 tips to improve post-op care

Just because surgery is over doesn’t mean that your patient is out of the woods. In fact, most deaths occur after, not during, surgery: 50% of canine and 60% of feline deaths occur within three hours of the end of anesthesia (see references).

It is important to avoid becoming complacent, despite the busyness of the day and what might seem like a “routine” surgery. As the saying goes, “there are routine surgeries, but there is no routine anesthesia.” Here are 10 essential tips to improve post-op care and help decrease post-op complications.

1. Extubation
The proper time to extubate is often based on a widespread misconception, sometimes called the “two swallows rule,” or the “3 swallows rule,” or the “5 swallows rule.” This is a very unfortunate urban legend, that can lead patients to serious trouble.

Two, three or even ten swallows may not mean that patients are alert enough to continue swallowing and breathing efficiently on their own. The more appropriate time to extubate is when a patient is alert, preferably has lifted their head up at least once, and begins to chew. The next challenge is to pull the endotracheal tube before the patient chews it in half!

This is especially true with brachycephalic dogs. They can notoriously seem wide awake, yet they sometimes tolerate an endotracheal tube for an hour. Some patients have an increased risk of aspiration (or suffocation) if the tube is pulled too early. Each patient recovering from anesthesia and/or surgery should be under the direct supervision of a technician until extubation – and beyond. We still need to remain alert afterwards: extubation doesn’t mean that recovery is over. It is just one step of the process.

2. Pain Management
Pain management is the cornerstone of postop care. Ideally, your nurses would pain score patients upon admission to the practice, and throughout their stay, including after surgery. This is the best way to be more objective about patients’ individual needs.

We say that “every patient is different,” yet we tend to offer the same analgesia to all of them.

Rather than sticking blindly to a cookbook recipe (every 4 hours, every 6 hours, every 8 hours), pain medications should be given based on the patient’s needs.

A patient’s pain level should be assessed periodically and treated as needed. Most practices have embraced the importance of preemptive pain management. It should continue beyond the OR. There are countless modalities we can choose from, depending on the patient and the procedure, including opioids, Constant Rate Infusion (CRIs) and anti-inflammatory drugs. Some colleagues are under the impression that CRIs are difficult, expensive or complicated to use. It’s quite the opposite: they are rather easy, affordable and simple to implement in a practice.

In addition, you don’t need a fancy specialty hospital to offer CRIs. Many family practices use them on a daily basis very successfully.

Pain management should be a practice-wide awareness, rather than an afterthought (or worse: a choice made by the client). Your nurses should be empowered to play an active role in pain management. After all, the veterinary oath includes “the prevention and relief of animal suffering.”

3. Dysphoria
It is very important to train your team to differentiate between pain and dysphoria.

Both can lead to crying, whining and bizarre behavior.

Dysphoric dogs who cry should stop when you sit next to them, interact with them, or call their name. Mild sedation such as the “rescue dose” of dexmedetomidine, is helpful for these patients. The goal is not to fully sedate them, but to “take the edge off” and help them relax as they recover.

Truly painful dogs who cry will not stop for any reason.
 

4. Warmth
Optimal body functions require optimal body temperature. Yet most patients wake up hypothermic after anesthesia. This in turn can affect blood pressure, infection rate and metabolism. There are many warming devices available to fight hypothermia during surgery. Yet your best efforts still may not prevent hypothermia. Therefore, it is important to continue to warm up your patient after surgery.

The same warming devices you use during surgery can be used after surgery.

As long as patients are hypothermic (<100 degrees F), their temperature should be taken every 30 minutes. This could be done even more often, e.g. every 15 minutes, especially in cats and small dogs, who could quickly become hyperthermic while unsupervised.

Options include:

• Heating lamps. They are certainly not ideal or safe but may be acceptable as long as hyperthermia or worse (skin burns) don’t occur.
• A heating pad or warming blanket can be moved from the OR to the recovery area. If at all possible, it would be ideal to have a separate warming device dedicated to recovering patients.
• Use towels or a blanket warmed up in the dryer. Be sure to cover the feet to decrease heat loss.
• Consider warming up the IV fluids, or using a heat source to warm up the fluids. Make sure it does not touch the patient’s skin, and that it is close to the IV catheter to be effective.

As you become familiar with the different techniques, you will notice that some work better for you than others. Or that you like some methods and dislike others. What matters, is that you and your nursing team become proficient enough to tailor various warming techniques to each patient. In other words, it will be more challenging to maintain the temperature of a Yorkie during a lengthy laparotomy, than the temp of an overweight Labrador during a quick mass removal.

Fighting and treating hypothermia is good patient care.
 

5. E-collars
E-collars are extremely important after surgery to prevent patients from self-mutilation (licking or chewing their incision), as well as preventing them from chewing out their IV catheter or damaging their IV line. Ideally, the E-collar should be placed before extubation to make it less stressful for the patient and technician alike.
 

6. Monitor
Walking away from a patient after extubation could be a risky proposition.

The CEPSAF study (see references) concludes that recovering patients should be monitored at least as closely as anesthetized patients.

A nurse should monitor the patient for postop complications so they can intervene early on, should an emergency arise. Parameters to track every 5 to 10 minutes include temperature, pulse, respiration, mucus membranes, capillary refill time and more. Continue to auscultate the heart and lungs. If the patient is still sedated or waking up slowly, leave the monitor hooked up to ensure that vitals are not going into dangerous territory.

If it’s difficult for you to bring an ECG closer to the patient, or measure blood pressure, at least consider monitoring pulse oximetry. There cannot be a set protocol for all patients. Protocols must be adjusted based on the patient’s needs: additional pain medications, a heat source to fight hypothermia, PCV, blood products, etc.

Vital signs and patient data should be documented, just as if the patient were still under anesthesia. If things go wrong, it is important to know where you started and where the trend is going in order to effectively treat any abnormality.

How can you accomplish this when there are so many other things to do?

One solution may be to have a dedicated nurse to recover patients if you have a busy surgery schedule. Even if you don’t have a big case load, the technician in charge of the anesthesia could remain in charge of patients until they are deemed safely recovered. This prevents miscommunication during the transition from one nurse to the next.

This means, at a minimum, that a patient should be:
    1. normothermic
    2. responsive
    3. comfortable and
    4. able to walk.

Ultimately, the greatest surgery, performed by the greatest surgeon, is only great if the patient goes back home safely.

4 little things that make a big difference…

Eye lube
We all know to place sterile lube on the cornea after induction. However, many patients may not blink effectively post-op, which can lead to ulcerations, especially in brachycephalic breeds. A wise precaution is to apply more sterile eye lube during recovery.

Emergency preparedness
Re-intubation equipment and emergency drugs should always be available near your recovery area. But in specific cases, it is wise to have them next to the patient. This includes any brachycephalic breed, patients recovering from neck and throat surgery and any critical patient who may arrest.

Radiographs
Don’t forget to take post-op radiographs after a cystotomy and foreign body surgery. Things can migrate in surprising ways, and certainly stones and foreign bodies can be left behind. Therefore, it is critical to take rads to confirm that all stones or all foreign bodies have been removed. Post-op rads after a cystotomy are now considered standard of care.

Lean weight
Dosing analgesic drugs should be calculated based on lean weight rather than actual weight. There is a paucity of information, but a good rule of thumb is to decrease the dosage proportionally to the amount of overweight.

For example, if a patient is 25% overweight, then decrease the dosage by 25%. This is especially true for drugs that are highly polar, aka water soluble, since they do not distribute to fat.

Communication tips

Discharge
Discharge instructions should be in writing and tailored to each patient to ensure owner compliance. Review them thoroughly with clients, line by line, to ensure that they know what to do, what not to do and what complications to look out for. Be specific about the medication schedule, including when to start them at home. Include information about an after-hours emergency clinic just in case there are complications.

Follow-ups
Owners must clearly understand the timing and cost of follow-up appointments: suture removal, follow up radiographs, with or without sedation, follow up visits with a doctor, physical therapy, or future medications that may be needed (for example, based on biopsy or culture results), etc.

Callbacks
Ideally, all surgery clients should be called the day after discharge. It shows that you truly care, and it’s a great time to answer questions and alleviate concerns. You know what is normal versus abnormal— most clients do not. Picking up their pet after surgery likely feels like a whirlwind, so clients likely don’t remember most of what was said during the discharge. Just because they keep nodding doesn’t mean they truly understand what you’re saying and what they’re supposed to do.

A common question is, “Should the pet be in the room during the discharge?” We would argue that the pet should not be present, as it is one more source of distraction. If you need to demonstrate something on the actual patient, then do it after going over the paperwork. Even though you feel you have been thorough and you sent home written discharge instructions, that doesn’t mean clients have a clue what they’re supposed to do.

We know the questions by heart: “Why won’t Kiki eat?” “Why won’t Kiki drink?” “Why hasn’t Kiki pooped yet?” “Is that discharge from the incision a normal thing?” “Why is he still groggy?” “He doesn’t seem in pain, can I stop giving the pain medications?”

Maybe you’ve heard those questions hundreds of times, but for your clients, it may be the first time. So do the right thing, reassure your clients and patiently help them follow your instructions. The outcome of your surgery and the health of your patient depend on it.